Provider Demographics
NPI:1518946243
Name:ANCONA, ROBERT J (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:ANCONA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1004
Mailing Address - Country:US
Mailing Address - Phone:718-422-7800
Mailing Address - Fax:718-422-7887
Practice Address - Street 1:84 FRONT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1004
Practice Address - Country:US
Practice Address - Phone:718-422-7800
Practice Address - Fax:718-422-7887
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT 005837152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
NYVUT005837152WX0102X
NYTUV005837-1152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01956312Medicaid
NYC38221Medicare PIN
NY01956312Medicaid